Received: 16 July 2019 Accepted: 19 August 2019

DOI: 10.1002/cre2.245

ORIGINAL ARTICLE

Influence of customized therapy for molar incisor

hypomineralization on children's oral hygiene and quality of life

Jana Fütterer1 | Markus Ebel1 | Katrin Bekes2 | Christian Klode3,4 |

Christian Hirsch5

1
Leo Löwenzahn Pediatric Dentistry Practice,
Bergisch Gladbach, Germany Abstract
2
School of Dentistry, Department of Pediatric Objective: The aim of this clinical follow-up study was to demonstrate the effects of
Dentistry, Medical University of Vienna,
different therapeutic strategies for hypomineralized teeth on patients' oral health.
Vienna, Austria
3
Department of Business Analytics and Data The treatment results were characterized by changes in the extent of hypersensitivity
Science, HMKW University of Applied Science, and plaque accumulation, as well as reductions in nutritional restrictions.
Cologne, Germany
4
Material and Methods: The impacts of therapy, including the use of fluoride varnish,
Faculty of Economics and Management,
Department of Knowledge Management, fissure sealants, fillings, and stainless steel crowns, were evaluated in 78 children
University of Marburg, Marburg, Germany
(mean age 8.5 years). We followed recommendations according to the Molar Incisor
5
School of Dentistry, Department of Pediatric
Dentistry, University of Leipzig, Leipzig,
Hypomineralisation Treatment Need Index for customized treatment. The Quigley
Germany Hein Index, the Schiff Cold Air Sensitivity Scale, Wong–Baker Faces Scale, and die-

Correspondence
Jana Fütterer, Leo Löwenzahn Pediatric
Dentistry Practice, Odenthaler Straße 132,
51465 Bergisch Gladbach, Germany.
+49/2202/32628.
Email: jcfuetterer@gmail.com
tary-limiting parameters were assessed before and after therapy for comparison.
Results: Plaque accumulation and hypersensitivity decreased after completion of
therapy. The improvements were greater for individual teeth (Quigley Hein Index for
teeth treated with stainless steel crowns from 4.19 to 2.54) than for those of the
whole dentition (high-severity category from 2.67 to 2.20). Problems with food
intake were minimized via therapy, with the greatest influence observed for patients
who were also in the high-severity category.
Conclusions: Therapy for affected teeth in children has positive effects on oral health
and quality of life.

KEYWORDS
hypersensitivity, MIH, MIH treatment, MIH Treatment Need Index, nutritional restrictions,
oral hygiene

1 | I N T RO D UC T I ON affect all deciduous and permanent teeth (Baroni & Marchionni,

Enamel disorders of molar incisor hypomineralization (MIH) and decid-
uous molar hypomineralization (DMH) have recently received increas-
ing attention from pediatric dentists worldwide. MIH describes a
developmental enamel defect of at least one permanent first molar
with or without affected permanent incisors (Weerheijm, Jalevik, &
Alaluusua, 2001). Since 2017, it has been shown that MIH/DMH can
2010). A recent meta-analysis of studies determined an average global
prevalence of MIH of 14.2% (Dave & Taylor, 2018). Posteruptive
enamel fractures can occur in affected teeth, which are frequently
associated with hypersensitivity and can lead to poorer dental
hygiene, problems with the intake of food (PwIoF), and decreased oral
health-related quality of life (Ebel et al., 2018). According to the fifth
German Oral Health Study (DMS V), the occurrence of MIH/DMH in

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provided the original work is properly cited.
© 2019 The Authors. Clinical and Experimental Dental Research published by John Wiley & Sons Ltd

Clin Exp Dent Res. 2020; 6:33–43. wileyonlinelibrary.com/journal/cre2 33

34
12-year-old children in Germany is higher than that of caries among
this population (Bekes & Hirsch, 2013). It has been shown that eight
out of ten 12-year-old children are free of tooth decay (81.3%), but
the same group has a 28.7% (Lygidakis et al., 2010; Weerheijm et al.,
2003) prevalence of MIH. This trend emphasizes the extraordinary
importance and attention among pediatric dentistry worldwide and
explains the variety of research in this field.
Ebel et al. (2018) verified severity-related consequences for the
oral hygiene and quality of life of MIH-/DMH-affected children. The
quantity and extent of structural disorders of affected teeth were cor-
related with increased consequences and restrictions: with the
increasing destruction of teeth accompanied by increased hypersensi-
tivity, as determined by the Schiff Cold Air Sensitivity Scale (SCASS)
and Wong–Baker Faces Scale (WBFS), plaque accumulation (Quigley
Hein Index [QHI]) significantly increased. In addition, the risk of die-
tary restrictions, characterized by pain during eating and drinking, as
well as pain during domestic and professional dental care, increased
with the disease severity and had a negative impact on the children's
development and susceptibility to caries (Jälevik & Klingberg, 2002;
Petrou et al., 2014).
Although studies and scientific research on MIH/DMH promote
awareness among pediatric dentists, no standardized treatment cur-
rently exists. A major issue challenging the assortment of optimal
treatment modalities is the diversity of the disorder, with its different
severity levels, including its various side effects, and the broad spec-
trum of available therapeutic approaches.
The MIH Treatment Need Index (MIH-TNI), introduced by Steffen
et al. (2017), presents recommendations for decision making when
planning individual treatment of MIH-affected teeth (Jälevik, 2010;
Steffen et al., 2017). The MIH-TNI differentiates affected teeth
according to the presence of hypersensitivity and the extent of
enamel defects. Furthermore, a treatment scheme has been devel-
oped for patients with a low or high risk of developing caries. The
TNI's therapeutic recommendations include pure dental prophylaxis
such as with fluoride varnish and fissure sealant and also restorative
restorations such as fillings, crowns, and extraction.
The purpose of this study was to investigate the influence of cus-
tomized therapeutic approaches based on the MIH-TNI on the dis-
ease-associated parameters investigated by Ebel et al. (2018). The
study sought to determine whether treatment of the affected teeth
could lead to improved oral hygiene (QHI) as well as the extent of
hypersensitivity (SCASS and WBFS) and nutritional restrictions
(PwIoF) that could be reduced as a result of therapy.
2 | MATERIALS AND METHODS
2.1 | Study design and ethics
In this follow-up study with repeated measures, the values for differ-
ent therapeutic approaches (fluoride varnish, fissure sealant, filling
with composite, stainless steel crown, and extraction) were analyzed
according to their impact on oral hygiene, hypersensitivity, and oral
health-related quality-of-life impairment regarding the severity of
FÜTTERER ET AL.
MIH/DMH in affected children. The Ethics Committee of the Univer-
sity of Leipzig, Germany (AZ: 187/17-ek), authorized this project. The
patients' legal representatives were informed in oral and written form,
and they consented to participate in this study according to the Dec-
laration of Helsinki guidelines.
2.2 | Setting
This investigation was based on a sample of consecutive patients
experiencing hypomineralized teeth, who were recruited from the Leo
Löwenzahn pediatric dentistry practice in Bergisch Gladbach, Ger-
many, between January and December 2017. The children were diag-
nosed on the basis of clinical examination under artificial light and
within the same dental unit as described in Ebel et al. (2018). Follow-
ing an initial examination period of patients from January to Decem-
ber 2017 conducted by the lead dentists (J. F. and M. E.), the patients
were treated with MIH severity-dependent therapy based on the
criteria of the MIH-TNI (Jälevik, 2010; Steffen et al., 2017). Therapy
was implemented for an average of 3 months after the initial examina-
tion, ranging from 2 to 401 days. Patients were followed up after ther-
apy by JF, on average, after 3 months (varying from 7 to 488 days) in
August 2017 to November 2018. The same parameters as in the initial
examination were collected.
2.3 | Participants
In total, 78 consecutive patients suffering from at least one
hypomineralized tooth were selected among the patient pool. The
guidelines of the European Academy of Pediatric Dentistry (Lygidakis
et al., 2010; Schwendicke et al., 2018; Weerheijm, 2003; Weerheijm
et al., 2003) were applied to diagnose the MIH-positive teeth: (a)
clearly definable opacity and/or buccal surfaces of the crowns, (b)
white-/yellow-to-brown discolorations, (c) MIH defects of at least 1
mm in diameter, (d) the presence of hypersensitivity, (e) the presence
of atypical restorations, and (f) the extraction of permanent teeth due
to MIH. Patients who did not collaborate willingly were excluded from
the survey. In addition, all patients undergoing orthodontic treatment
during the study period were excluded, as orthodontic treatment may
have a negative impact on the ability of a patient to perform proper
oral hygiene.
2.4 | Sample size
G*Power Software (www.gpower.hhu.de) was used to analyze the
sample size. Within this follow-up study, the difference between sev-
eral premeasurement and postmeasurement (matched) pairs should
be tested according to their statistical significance by applying either
analysis of variance (ANOVA) using mean differences or Wilcoxon test
using rank differences. We took the standard default thresholds
(effect size = 0.5) and used 95% confidence intervals due to the com-
mon error probabilities of 5%. For the model applications, G*Power
suggested a sample size of n = 45 for the ANOVA and n = 47 for the
Wilcoxon test. Although we did not expect significant differences in
FÜTTERER ET AL.
gender (see Ebel et al., 2018), we drew a larger sample to establish a
nearly equal gender ratio. This follow-up study included data from 78
patients (37 girls and 41 boys).
2.5 | Variables
The QHI was defined as the quantitative outcome variable. The
SCASS and WBFS were defined as intermediating quantitative vari-
ables, which may work as dependent or independent variables (see
Ebel et al., 2018). The tooth-related MIH groups (I–III), patient-related
severity (low-severity category [LSC], medium-severity category
[MSC], and high-severity category [HSC]), and treatment groups (fluo-
ride varnish, sealant, filling, SSC, and extraction) served as predictors.
In addition, we used additional exogenous variables, including gender,
social status groups, and age, and two binary control variables: PwIoF
and tooth decay risk (TDR).
2.6 | Measurements
Oral hygiene was measured in terms of plaque distribution, as several
studies support the use of the QHI (Quigley & Hein, 1962)
to determine overall dental health and caries risk (Menghini, Steiner, &
Imfeld, 2008; Newman, 1986; Walsh, 2006). Caries risk
was classified according to the recommendations of the Deutsche
Arbeitsgemeinschaft für Jugendzahnpflege e.V (DAJ; 1993) using the
dmft/DMFT index (the single-value sum of the decayed D(d), missing
M(m), and filled F (f)(teeth). To access plaque accumulation, the obser-
vations after applying a plaque revelator were scaled into five classes
(PlaqSearch, TePe®, Tepe D-A-CH GmbH, Hamburg, Germany): 0: no
plaque; 1: isolated plaque islands; 2: a contiguous plaque line up to 1
mm thick at the gingival margin; 3: plaque expansion in the cervical
tooth thirds; 4: plaque expansion to the middle third; and 5: plaque
expansion to the coronal third.
Furthermore, the SCASS (Schiff, Dotson, Cohen, De WV, & Volpe,
1994) and the WBFS20 were used to determine the sensitivity of
teeth to an air stimulus and to test personal pain experience. For stan-
dardized data collection, the SCASS was categorized according to the
patient's reaction when applying a dental unit air syringe (pressure: 60
± 5 psi, temperature: 20 ± 2 C, and application: 1–2 s at a distance of
1 cm from the tooth). The grading was 0 (no response), 1 (response
but no removal request), 2 (removal request and patient movement
away from the airflow), or 3 (removal request, leaning away from the
stimulus and a feeling of pain). In addition to the examination of all
MIH-affected teeth, every unaffected tooth from the same dental
group (e.g., all first molars) was also evaluated. During the same proce-
dure, the WBFS score was found as a measurement for the subjective
experience of pain. The patients were asked to match their intensity
perception to a display showing a scale reaching from a smiling (score
0) to a crying (score 10) face (Wong & Baker, 1988).
The study participants and their legal guardians were interviewed
regarding MIH-/DMH-dependent PwIoF. The Child Perception Ques-
tionnaire (Bekes, John, Schaller, & Hirsch, 2011) served as the basis
for documenting the patients' overall nutritional restrictions. The
35
children were queried in greater detail regarding whether they experi-
enced problems or pain with chewing solid food or with eating and
drinking hot, cold, or spicy items. In terms of validation, one negative
association was sufficient to characterize the patient as a restricted
eater.
The patients' data summarizing the severity of the MIH/DMH,
according to Mathu-Muju and Wright (2006), and the number of
affected teeth were classified into three severity categories. The
patients were rated according to their MIH/DMH severity (Ebel et al.,
2018): Mildly affected teeth were scored as 0 “risk points” as they did
not affect the QHI (Quigley & Hein, 1962) and, therefore, the caries
risk (TDR); moderately affected teeth were rated with 2 points; and
severely affected teeth received 3 points. The sum of risk points per
person was calculated to determine the personal severity score, which
combines the evaluated number and decay of affected teeth. Thereaf-
ter, the patients were classified within an LSC if they had a score of 0,
within the MSC with a score of 2–4 points, or within the HSC with a
score of >4 points.
The MIH-TNI, as described by Steffen et al. (2017), was used to
compare the impacts of different treatments. Patients with no hypo-
mineralization were classified as MIH-TNI 0; MIH-affected patients
without hypersensitivity or enamel defects were classified as MIH-
TNI 1; patients with MIH and without hypersensitivity but with
enamel defect were classified as MIH-TNI 2; patients with MIH and
hypersensitivity but without enamel defect were classified as MIH-
TNI 3; and MIH-affected patients with both hypersensitivity and
enamel defects were classified as MIH-TNI 4. A suitable therapy was
chosen on the basis of each patient's MIH-TNI status (Jälevik, 2010;
Steffen et al., 2017).
2.7 | Bias
The SCASS and WBFS values depend on the personal sensation of
pain and can change with age or the examiner's proceedings. The QHI
could be biased by the children's general teeth-cleaning habits, such
as additional brushing of teeth before the appointment and by the
choice and application of the plaque-disclosing agent. To prevent dif-
ferences, the QHI was assessed with the same agent in every patient.
The PwIoF could be affected by the children's general eating habits,
including personal preferences for or against solid and spicy food. In
terms of classifying therapy success, note that every child has a differ-
ent personal pain tolerance and that an adaption of nutrition caused
by persistent hypersensitivity is within the realm of possibility.
In this context, the possible occurrence of material application
errors due to incorrect storage, use past the expiration date, or inac-
curate usage and noncompliance with the manufacturer's rec-
ommended polymerization times could influence the therapeutic
success. Further, young patients' personal behavior and compliance
with therapy can interfere with the dentist's ranking (QHI, SCASS,
WBFS, and PwIoF) and treatment methods (e.g., children who are
being restless, fidgety, or extremely anxious can hinder the draining of
the operating environment and complicate the treatment options and
assessment of the indices and scores). Another limitation of the
36 FÜTTERER ET AL.

treatment can be inadequate levels of anesthesia, which my lead to TABLE 1 Summary of sample data (n = 78 patients)
difficulties in treatment due to the sensitivity of damaged teeth. In the
% (n)
case of an incomplete excavation, the restorative margins may not lie
Gender
within the healthy tooth structure, which could cause painful side
Male 52.6 (41)
effects and, therefore, possible bias.
Female 47.4 (37)
Age
2.8 | Statistical methods  8.5 years

In our follow-up study, we examined the improvements to our quanti- Range 3–15 years
tative measures with respect to different tooth groups (MIH) and Severity categories
patient groups (e.g., MSC) and various treatments. Progress was indi- LSC 30.8 (24)
cated by improved mean values of our measurements (using ANOVA) MSC 33.3 (26)
or by improved Z values (using the Wilcoxon test). The significance of HSC 35.9 (28)
the hypothesis using ANOVA was accepted if (a) the two confidence dmft/DMFT
intervals did not overlap, (b) the mean of group A was not located
Mean dmft (3–5 years) 0.64 (11)
within the confidence interval of group B, and (c) the p value was less
Mean dmft/DMFT (6–9 years) 2.83 (48)
than 5%. For subsequent Wilcoxon tests, significance for p values
Mean DMFT (10–15 years) 1.11 (19)
lower than 5% was accepted.
TDR
After acquiring information through examination or questioning,
High 21.8 (17)
the data were dictated to a dental assistant, who transferred them to
a database via an input mask (Microsoft Access 2016). The mask was Normal 78.2 (61)

used to build the platform for a lower error rate and allowed straight- Social status

forward verification of the accuracy and completeness of the data. High 25.6 (20)
The survey results were transferred to and analyzed in Microsoft Normal 74.4 (58)
Excel 2016 in tabular form. The diagrams and graphics listed in this Abbreviations: HSC, high-severity category; LSC, low-severity category;
work were created with the same program. MSC, medium-severity category; TDR, tooth decay risk.

Group II (30.1%), and 48 teeth as Severity Group III (21.9%;

3 | RESULTS
3.1 | Participants
In total, 78 children were included in the study, and the patients' gen-
ders were nearly equally distributed, with 37 female and 41 male
patients. The mean age of the examined children was 8.5 years, rang-
ing from 3 to 15 years of age, again with no significant difference con-
cerning gender. Additionally, 15% (n = 12) of the patients were non-
Caucasian; 25.6% of the children (n = 20) could be assigned to a high
social status, meaning that at least one parent had an academic
degree; 61 children (78.2%) showed a normal dental caries risk; and
17 (21.8%) children were classified as high TDR. The mean dmft/
DMFT was highest in the group of 6- to 9-year-old patients (2.83).
Furthermore, 24 children (30.8%) could be assigned to the LSC, 26
(33.3%) to the MSC, and 28 (35.9%) to the HSC, reaching an almost
equal sample size in the individual groups (Table 1).
Appendix A). The MIH-TNI (Jälevik, 2010; Steffen et al., 2017) was
used as a guideline to choose comparable therapeutic approaches for
patients suffering from different consequences of the hypo-
mineralization (Table 2). Most of the teeth (n = 107) were in the TNI 1
class, excluding hypersensitivity and posteruptive enamel break-
downs. Additionally, 52 of the TNI 1 teeth received only fluoride var-
nish as prophylaxis, another 50 teeth had fissure sealants, and five
teeth were filled. The two teeth graded TNI 2 were restored with fill-
ings. The TNI 3 group consisted of 30 teeth, among which 19 received
fissure sealants, six were treated with fillings, and five had fluoride
applied in varnish form. TNI 4 teeth suffering from hypersensitivity
and enamel breakdown were mainly restored with fillings (n = 48) or
stainless steel crowns (n = 26).
T A B L E 2 Differentiation of customized therapy (tooth related)
based on the Molar Incisor Hypomineralisation Treatment Need Index
(Steffen et al., 2017)

TNI 1 TNI 2 TNI 3 TNI 4

3.2 | Main results Total 107 2 30 80
Fluoride varnish 52 0 5 4
A total of 1,831 teeth were included in the study, comprising 865
Fissure sealant 50 0 19 1
(47.2%) deciduous and 966 (52.8%) permanent teeth. Among them,
Filling 5 2 6 48
219 (12%) teeth were MIH positive, of which 9.1% (n = 20) were
SSC 0 0 0 26
deciduous and 90.9% (n = 199) were permanent. The differentiation
Extraction 0 0 0 1
of MIH teeth according to their severity showed that 105 teeth could
be classified as MIH Severity Group I (48%), 66 teeth as Severity Abbreviations: SSC, stainless steel crown; TNI, Treatment Need Index.
FÜTTERER ET AL. 37

Table 3 shows the therapeutic approaches according to the sever-
ity classification of the 219 MIH teeth. Thereby, the MIH severity
group was positively correlated with the chosen therapy strategy (chi-
squared test: p = .00) defined by the TNI (Jälevik, 2010; Steffen et al.,
2017). The majority of teeth treated with fluoride varnish within a
prophylaxis session (n = 61) were classified as MIH class I teeth
(86.9%). Among the obtained teeth, 70 were treated with fissure seal-
ants, whereas fillings were applied to 61 teeth, most of which were
classified as MIH I or II. The 26 teeth that needed a stainless steel
crown could be assigned to MIH Class III in most cases (80.8%). In
addition, one tooth within the MIH III category was not worth
retaining and had to be removed. As a consequence, this tooth was
excluded from further evaluation, leaving a group size of 218 MIH-
positive teeth.
Deeper analysis included 218 MIH-positive teeth, which were dif-
ferentiated by the allocated therapeutic approach and by the MIH
severity before and after the treatment (Tables 4–6). Table 4 presents
a significantly decreased QHI in all categories after treatment, with
the exception of the prophylaxis (fluoride varnish). The more severe
the MIH is, the better the QHI range after completion of the treat-
ment, decreasing from QHI 2.56 to 2.11 in teeth treated with sealants,
compared with a QHI from 4.19 to 2.54 in teeth prepared with stain-
less steel crowns. Furthermore, the QHI was significantly decreased
after therapy in all MIH severity categories. The validation of the
SCASS (Table 5) resulted in statistically consistent values before and
after treatment if the teeth were treated with fluoride varnish (from
0.34 to 0.25) or fissure sealants (0.66 to 0.64). Teeth that were pro-
vided with fillings (SCASS from 1.87 to 1.56) or steel crowns (2.50 to
1.77) showed significantly decreased hypersensitivity. Similar results
were obtained using the WBFS to assess the hypersensitivity (Table 6).
In teeth treated with fluoride varnish and sealants, the WBFS
decreased but showed no statistical significance, whereas teeth pro-
vided with fillings (WBFS 5.34 to 2.51) or crowns (WBFS 6.81 to
2.46) showed clear improvements. In addition, MIH II teeth also
showed a decreased WBFS (4.38 to 2.18). Determination of the
SCASS and WBFS scores before and after treatment revealed the big-
gest improvements in terms of hypersensitivity in the MIH III category
(SCASS 2.32 to 1.70 and WBFS 6.60 to 3.11).
Table 7 provides an overview of the QHI changes per person
before and after the application of each therapeutic approach. Chil-
dren in the LSCs did not benefit from the medical care (LSC: from
1.12 to 1.16), whereas the mean plaque accumulation of patients

TABLE 3 Differentiation of customized therapy (tooth related) for MIH-affected teeth (Mathu-Muju & Wright, 2006, n = 219 teeth)

All MIH I MIH II MIH III

n % n % n % n %
Total 219 100.0 105 48.0 66 30.1 48 21.9
Fluoride varnish 61 27.8 53 86.9 8 13.1 0 0.0
Fissure sealant 70 32.0 49 70.0 21 30.0 0 0.0
Filling 61 27.8 3 4.9 32 52.5 26 42.6
SSC 26 11.9 0 0.0 5 19.2 21 80.8
Extraction 1 0.5 0 0.0 0 0.0 1 100.0

Abbreviations: MIH, molar incisor hypomineralization; SSC, stainless steel crown.

TABLE 4 Test for significant differences between the mean Quigley Hein Index before and after therapy (tooth related), including 95% CIs

ANOVA Wilcoxon

Before After
n
Therapy 218 Mean 95% CI Mean 95% CI Difference p value
Fluoride varnish 61 2.15 [1.91, 2.39] 2.05 [1.81, 2.29] 0.10 .40
Fissure sealant 70 2.56 [2.33, 2.78] 2.11 [1.89, 2.34] 0.45 .00
Filling 61 3.52 [3.28, 3.77] 2.23 [1.99, 2.47] 1.29 .00
SSC 26 4.19 [3.82, 4.56] 2.54 [2.17, 2.91] 1.65 .00

Before After
n
MIH a
218 Mean 95% CI Mean 95% CI Difference p value
MIH I 105 2.13 [1.96, 2.31] 1.94 [1.76, 2.12] 0.19 .03
MIH II 66 3.35 [3.13, 3.57] 2.30 [2.08, 2.53] 1.05 .00
MIH III 47 4.02 [3.76, 4.28] 2.53 [2.26, 2.80] 1.49 .00

Abbreviations: ANOVA, analysis of variance; CI, confidence interval; MIH, molar incisor hypomineralization; SSC, stainless steel crown.
a
Mathu-Muju and Wright (2006).
38 FÜTTERER ET AL.

TABLE 5 Test for significant differences between the mean Schiff Cold Air Sensitivity Scale before and after therapy (tooth related), including
95% CIs

ANOVA Wilcoxon

Before After
n
Therapy 218 Mean 95% CI Mean 95% CI Difference p value
Fluoride varnish 61 0.34 [0.16, 0.53] 0.25 [0.04, 0.45] 0.09 .01
Fissure sealant 70 0.66 [0.48, 0.83] 0.64 [0.45, 0.84] 0.02 .74
Filling 61 1.87 [1.68, 2.05] 1.56 [1.35, 1.77] 0.31 .03
SSC 26 2.50 [2.22, 2.78] 1.77 [1.45, 2.09] 0.73 .01

Before After
n
MIHa 218 Mean 95% CI Mean 95% CI Difference p value
MIH I 105 0.29 [0.16, 0.41] 0.25 [0.10, 0.40] 0.04 .32
MIH II 66 1.62 [1.46, 1.78] 1.44 [1.25, 1.63] 0.18 .14
MIH III 47 2.32 [2.13, 2.51] 1.70 [1.48, 1.92] 0.62 .00

Abbreviations: ANOVA, analysis of variance; CI, confidence interval; MIH, molar incisor hypomineralization; SSC, stainless steel crown.
a
Mathu-Muju and Wright (2006).

TABLE 6 Test for significant differences between the mean Wong–Baker Faces Scale before and after therapy (tooth related), including 95%
CIs

ANOVA Wilcoxon

Before After
n
Therapy 218 Mean 95% CI Mean 95% CI Difference p value
Fluoride varnish 61 1.16 [0.67, 1.66] 1.07 [0.57, 1.56] 0.09 .13
Fissure sealant 70 1.63 [1.16, 2.09] 1.24 [0.78, 1.71] 0.39 .02
Filling 61 5.34 [4.85, 5.84] 2.51 [2.01, 3.01] 2.83 .00
SSC 26 6.81 [6.05, 7.57] 2.46 [1.70, 3.22] 4.35 .00

Before After
n
MIH a
218 Mean 95% CI Mean 95% CI Difference p value
MIH I 105 0.85 [0.51, 1.19] 0.75 [0.40, 1.11] 0.10 .16
MIH II 66 4.38 [3.95, 4.81] 2.18 [1.74, 2.63] 2.20 .00
MIH III 47 6.60 [6.09, 7.10] 3.11 [2.58, 3.63] 3.49 .00

Abbreviations: ANOVA, analysis of variance; CI, confidence interval; MIH, molar incisor hypomineralization; SSC, stainless steel crown.
a
Mathu-Muju and Wright (2006).

TABLE 7 Comparison of mean Quigley Hein Index (patient related) before and after therapy concerning severity categories (Ebel et al., 2018)

ANOVA Wilcoxon

Before After
n
Severity category 78 Mean 95% CI Mean 95% CI Difference p value
Low 24 1.12 [0.86, 1.37] 1.16 [0.89, 1.44] −0.04 .81
Medium 26 2.15 [1.90, 2.39] 1.96 [1.70, 2.23] 0.19 .04
High 28 2.67 [2.43, 2.91] 2.20 [1.94, 2.45] 0.47 .00

Abbreviations: ANOVA, analysis of variance; CI, confidence interval.

classified within the MSC or HSC showed improvements (MSC: from mean QHI of greater or less than 0.5 indicated a declined or improved
2.15 to 1.96; HSC: from 2.67 to 2.20). Therefore, the reduction of condition, and 75% of the children in the LSC showed constant plaque
QHI in the HSC group was statistically significant. A change in the accumulation before and after care. Although a similar constant
FÜTTERER ET AL.
pattern was assessed for patients from the MSC (73.1%), half of the
patients in the HSC showed improvement after therapy (Appendix F).
Table 8 characterizes the MSC and HSC according to their prob-
lems with food intake before and after specialized treatment. In both
groups, therapy resulted in a significant decrease in PwIoF. Before
treatment, 12 patients from the MSC and 21 patients from the HSC
suffered from general PwIoF, compared with seven MSC patients and
14 HSC patients after medical care. Differentiation of the problems
shows significant improvement for children in the HSC and for
patients who felt restricted in terms of chewing hot or cold (p = .09)
or spicy food (p = .02) but not for children who had problems with
eating solid food. Primarily in the MSC, therapy reduced problems
with eating hot or cold food from 46.2% to 26.9%.
Patients in the LSC did not have any problems with food intake
(Appendix E). Although PwIoF status did not change in 73.1% of chil-
dren from the MSC, participants grouped in the HSC benefited from
therapy in 67.9% of the cases.
Additionally, the number of teeth was grouped by therapeutic suc-
cess in terms of decreasing QHI, SCASS, and WBFS scores (Appendi-
ces B–D). The specific treatment ranged from prophylaxis to the
insertion of stainless steel crowns. Teeth restored with crowns
showed a predominant improvement in all scales (QHI: 80.8%, SCASS:
61.5%, and WBFS: 88.5% of teeth), whereas the percentage of teeth
with fillings mainly showed improvements in a lower QHI (80.3%) and
in a lower WBFS (78.7%). The teeth that were treated with milder
therapy (fluoride varnish and fissure sealants) mostly maintained their
scores on the QHI, SCASS, and WBFS, including a range from 47.1%
to 90.2% of teeth with constant values. Teeth ranked as MIH I
showed mainly constant values of QHI (54.3%), SCASS (83.8%), and
WBFS (89.5%) before and after treatment, whereas teeth placed in
MIH Classes II and III were mostly characterized by improved values.
Patients with MIH III teeth benefited the most from the treatment:
83% of the MIH III teeth showed less plaque accumulation (QHI),
48.9% had a lower SCASS score, and 80.9% had a lower rating on the
WBFS. Children grouped into the LSC mainly stayed at the same level
in terms of plaque accumulation (QHI: 75%) and PwIoF (100%). The
same trend was prominent among the children grouped into the MSC.
Most of the patients showed neither an improvement nor a decline in
TABLE 8 Ratios for different severity categories (patient related) concerning PwIoF before and after therapy
Wilcoxon
MSC
33.3 (26)
Before After
Total n = 78 % (n) % (n)
PwIoF “yes” 46.2 (12) 26.9 (7)
PwIoF hot or cold food “yes” 46.2 (12) 26.9 (7)
PwIoF solid food “yes” 11.5 (3) 3.9 (1)
PwIoF spicy food “yes” 11.5 (3) 2.6 (2)
Note. There were no PwIoF in the low-severity category.
Abbreviations: HSC, high-severity category; MSC, medium-severity category; PwIoF, problems with the intake of food.
39
QHI (73.1%) or PwIoF (73.1%). The 28 patients from the HSC
benefited the most from the specialized treatment, characterized by
an improved QHI (50%) and PwIoF (67.9%).
4 | DISCUSSION
The present study demonstrates significant correlations between
the severity of MIH, the therapeutic approach applied, the presence
of hypersensitivity, and changes in food intake. MIH and DMH show
several side effects, such as the exposure of dentin due to enamel
breakdown, which might lead to increased hypersensitivity and
decreased oral hygiene. Furthermore, this results in a higher risk of
developing dentin caries. Moreover, patients can suffer from
problems during eating or drinking of hot, cold, spicy, or particularly
solid food (Ebel et al., 2018). Specialized medical care is essential for
improving MIH-affected patients' situations. Therefore, dentists
worldwide are challenged by the differentiation of the MIH-affected
area and must prevent further breakdown and secondary caries as
well as choose the optimal therapeutic approach, material, and time
point for children's treatment (Kohlboeck, Heitmueller, Neumann,
et al., 2013; Krishnan & Ramesh, 2014; Mathu-Muju & Wright, 2006;
Newman, 1986; Walsh, 2006). As the etiology of MIH presently
remains unclear (Silva, Scurrah, Craig, Manton, & Kilpatrick, 2016;
Taylor, 2017), only early diagnosis and treatment at the start of denti-
tion can ensure the best possible therapy. Unfavorably, clinicians'
seem to have a broad disparity of opinions on the best treatment
options for MIH-affected teeth (Kopperud, Pedersen, & Espelid,
2017). The best option for these children is to prevent posteruptive
risks, including by monitoring for cariogenic nutrition, balanced fluo-
ride levels, and pH values in the oral region, together with sufficient
oral hygiene and regular monitoring by a dentist. The high incidence
of MIH-affected patients can be explained by the location and special-
ization of the practice. It is the only specialized pediatric practice in a
densely populated area of North Rhine-Westphalia, with a total
recruitment area of 100,000 inhabitants that treats children requiring
general anesthesia or major rehabilitation. Taking the patient pool as
an advantage for this study, the severity categories were based on
HSC
35.9 (28)
Before After
p value % (n) % (n) p value
0.00 75.0 (21) 50.0 (14) .01
0.03 75.0 (21) 39.3 (11) .09
0.05 57.1 (16) 10.7 (3) .20
0.16 39.3 (11) 0.0 (0) .02
40
equal participant numbers, including patients suffering from the
highest MIH score.
The MIH-TNI provides standardized guidelines for choosing treat-
ment options according to MIH status, as the index was designed for
this purpose (Jälevik, 2010; Steffen et al., 2017). This study evaluated
the recommended treatment options according to the improvements
after therapy.
In mild cases, fluoride varnish was the treatment of choice and
resulted in enamel strengthening, which can contribute to the preven-
tion of caries. All patients treated with this approach were rec-
ommended for therapy of the MIH-affected teeth. However, some
parents or legal guardians rejected a specific therapy for MIH teeth,
especially in cases without hypersensitivity or general pain or if the
recommended therapy would have included anesthesia. These chil-
dren with teeth ranked in the TNI 3 (n = 5) and 4 (n = 4) groups were
monitored and treated with prophylaxis. The analysis of plaque accu-
mulation and hypersensitivity before and after treatment (OHI: 2.15
to 2.05, SCASS: 0.34 to 0.25, and WBFS: 1.16 to 1.07) confirmed the
absence of suffering.
Sealants were used to reduce plaque accumulation on fissures and
to improve sensitivity within exposed areas through adhesive mount-
ing. Defect-oriented restorations for maintaining tooth vitality were
performed in cases of exposed dentin and/or the development of car-
ies. Around one third of the teeth in the MIH I group and two thirds
of the teeth in the MIH II group were treated with sealants. All param-
eters decreased after treatment. Hypersensitivity was higher in this
particular group, as represented in the upper values of the SCASS and
WBFS, compared with teeth to which fluoride varnish was applied.
The higher plaque accumulation in this group could also be explained
by the increased hypersensitivity and the observation that fissure
sealants often need to be restored, which further promotes lasting
sensitivity.
The teeth treated with fillings were mainly grouped into MIH II (n =
32) and III (n = 26), with an MIH-TNI of 4 (n = 48). The high QHI scores
before treatment support the classification because the tooth surfaces
were generally rough but improved with treatment (3.52 to 2.23). The
recommended treatment showed large improvements in this group, as
the subjective feeling of pain (WBFS 5.34 to 2.51) and the SCASS score
(1.87 to 1.56) both significantly decreased. Nevertheless, fillings often
result in posttreatment side effects, such as prolonged feelings of pain
or sensitivity due to drilling. These effects can be the reason for an
extended recovery time, which can result in a longer postoperative
time period (e.g., 6 months) until the follow-up examination.
Stainless steel crowns were used if more than two thirds of the
tooth surface was damaged, if the patient's hypersensitivity would not
allow for the application of a filling, or if the filling did not produce
any improvement in the patient's status. Mainly MIH III teeth classi-
fied as TNI 4 were provided with crowns. The application of the crown
immediately evened out rough and porous surfaces, explaining the
striking decrease in the QHI score from 4.19 to 2.54 in this study. Fur-
thermore, the SCASS (2.5 to 1.77) and WBFS (6.81 to 2.46) scores
showed significant decreases, supporting this choice of crown
FÜTTERER ET AL.
application for severe cases. The pain that these children experienced
could mainly be reduced by applying crowns.
Recommendations for extraction and optimized teeth position
were obtained from Jälevik and Möller, who suggested extraction if
the pulpitis was irreversibly damaged, the defect was too subgingival,
or treatment was not possible under inhalation anesthesia (Jälevik,
2010; Steffen et al., 2017). In this study, only one of 219 teeth
fulfilled these criteria and had to be removed.
Note that pain perception and restrictions are most likely to adapt
as the children age, as this study lasted for 1 year. The estimation of
felt pain (WBFS) and the reaction to an air stimulus (SCASS) are not
free of personal bias, especially if the children experienced several
treatment sessions including drilling or anesthesia and became accus-
tomed to the procedure.
This study focused on the comparability between different
severely damaged teeth and patient suffering. Therefore, participants
were nearly equally distributed into the three severity categories, from
LSC to HSC. Patients grouped into the LSC and MSC included only a
few mild to moderate cases of MIH teeth per patient, with a relatively
small impact on overall oral hygiene. Consequently, patients from the
LSC and MSC groups did not show great changes in the QHI score,
whereas children from the HSC were characterized by severe cases of
MIH teeth or had several damaged teeth. In comparison, these severely
hypomineralized teeth had a greater impact on overall oral hygiene.
Therefore, these HSC patients showed the greatest improvement after
therapy, with a mean QHI score decrease from 2.67 to 2.20.
A similar picture can be seen in terms of nutritional restrictions.
Patients from the LSC were not but children from the MSC and HSC
were challenged with PwIoF. Thus, the HSC showed the best
improvements following the application of specific therapeutic
approaches. Treatment could decrease the hypersensitivity of the
teeth and thermal stimuli, and spiciness and chewing became less
painful for the children.
The results of this study unveiled how patients suffering
heavily from MIH-affected teeth in terms of plaque accumulation,
hypersensitivity, and nutritional restrictions benefited the most from
specific therapeutic approaches. The improvements in the severe
cases further support the use of the Treatment Need Index (Jälevik,
2010; Steffen et al., 2017) as a guideline for therapy. A more standard-
ized strategy by which to treat MIH could provide significant benefits
to all children suffering from this enamel disorder and offer support to
dentists worldwide in terms of choosing a form of therapy (Kopperud
et al., 2017). Although this study could benefit many children, severely
damaged teeth are not completely symptom free after the treatment
of choice and must be monitored over the long term. This finding
shows, once more, that children suffering from MIH require additional
care and persistent therapy from qualified dentists.
5 | C O N CL U S I O N
This study confirms the hypothesis that patients benefit from therapy
for MIH-damaged teeth and that treatment can reduce
FÜTTERER ET AL.
hypersensitivity and improve the ability to ensure oral hygiene. Addi-
tionally, the number of dietary restrictions decreased after therapy. All
the examined effects were significant for individual affected teeth but
rather low throughout the overall dentition. These results imply that
more severely damaged teeth are in greater need of invasive therapy
than mildly damaged ones. These results underline the importance of
treating MIH-damaged teeth to help relieve children's suffering and
improve their quality of life.
AUTHOR CONTRIBUTIONS
J. F., K. B., C. H., and M. E. conceived the study's premise. J. F. per-
formed the clinical testing, led the data collection, and wrote the man-
uscript. C. K. analyzed the data, completed the statistical analysis, and
wrote the statistical portion of the manuscript. K. B., C. H., C. K., and
M. E. interpreted the results and critically reviewed the manuscript.
CONF LICT OF IN TE RE ST
The authors do not have any financial interest in the companies
whose materials are included in this article.
CLIN ICAL SIGNIF ICANCE
To minimize hypersensibility, MIH-affected teeth require selective
therapy, depending on the severity of the damage. This is the only
way to improve children's oral hygiene and to minimize limitations to
food intake. Prior categorization of damaged teeth using the MHI-TNI
method simplifies the search for a suitable therapy.
ORCID
Jana Fütterer https://orcid.org/0000-0003-0339-3236
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n Declined Constant Improved
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Therapy 218 % (n) % (n) % (n)
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of the European meeting on MIH held in Athens, 2003. European Jour- Fluoride varnish 61 18.0 (11) 54.1 (33) 27.9 (17)
nal of Paediatric Dentistry, 4, 111–113. Fissure sealant 70 10.0 (7) 47.1 (33) 42.9 (30)
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MIHa 218 % (n) % (n) % (n)
MIH I 105 15.2 (16) 54.3 (57) 30.5 (32)
MIH II 66 7.6 (5) 22.7 (15) 69.7 (46)
How to cite this article: Fütterer J, Ebel M, Bekes K, Klode C,
MIH III 47 6.4 (3) 10.6 (5) 83.0 (39)
Hirsch C. Influence of customized therapy for molar incisor
a
hypomineralization on children's oral hygiene and quality of Mathu-Muju and Wright (2006).
life. Clin Exp Dent Res. 2020;6:33–43. https://doi.org/10.1002/ Note. We defined declined/improved as a deviation greater/lower than
0.5 mean QHI.
cre2.245
Abbreviations: MIH, molar incisor hypomineralization; SSC, stainless steel
crown.

APPENDIX A

SUMMARY TABLE OF T OOTH DATA IN 7 8 P ATIENTS

WITH MIH (MATHU-MUJU & W RI GHT, 2006, N= 1, 8 31
APPENDIX C
T EE T H )
CHANGE I N THE MEAN SCH IFF COLD AIR SENSITIVITY
(n = 1831 teeth)
SCALE B EF ORE AND AFTER THERAPY(TOOTH R ELATED)
% (n)
n Declined Constant Improved
Dentition Therapy 218 % (n) % (n) % (n)
Primary teeth 47.2 (865)
Fluoride varnish 61 0.0 (0) 90.2 (55) 9.8 (6)
Permanent teeth 52.8 (966)
Fissure sealant 70 10.0 (7) 75.7 (53) 14.3 (10)
MIH affected 12.0 (219)
Filling 61 16.4 (10) 47.5 (29) 36.1 (22)
Primary teeth 9.1 (20)
SSC 26 23.1 (6) 15.4 (4) 61.5 (16)
Permanent teeth 90.9 (199)
n Declined Constant Improved
MIH I 48.0 (105) MIHa 218 % (n) % (n) % (n)
MIH II 30.1 (66)
MIH I 105 4.8 (5) 83.8 (88) 11.4 (12)
MIH III 21.9 (48) MIH II 66 16.7 (11) 54.5 (36) 28.8 (19)
Abbreviation: MIH, molar incisor hypomineralization. MIH III 47 14.9 (7) 36.2 (17) 48.9 (23)
a
Mathu-Muju and Wright (2006).
Note. We defined declined/improved as a deviation greater/lower than 1.
Abbreviations: MIH, molar incisor hypomineralization; SSC, stainless steel
crown.
FÜTTERER ET AL. 43

APPENDIX D
APPENDIX F

CHANG E IN T HE ME AN W ONG– BAKER FACES SCALE

CHANGE IN THE MEAN QUIGLEY HEIN INDEX BEFORE
BE FORE AND AFTER THERAPY (TOOTH R ELATED)
AND AF T E R THE R AP Y (PAT I E N T R ELA T ED)

n Declined Constant Improved n Declined Constant Improved

Therapy 218 % (n) % (n) % (n) Severity category 78 % (n) % (n) % (n)
Fluoride varnish 61 1.6 (1) 91.8 (56) 6.6 (4) Low 24 8.3 (2) 75.0 (18) 16.7 (4)
Fissure sealant 70 5.7 (4) 64.3 (45) 30.0 (21) Medium 26 7.7 (2) 73.1 (19) 19.2 (5)
Filling 61 3.3 (2) 18.0 (11) 78.7 (48) High 28 7.1 (2) 42.9 (12) 50.0 (14)
SSC 26 7.7 (2) 3.8 (1) 88.5 (23) Note. We defined declined/improved as a deviation greater/lower than
n Declined Constant Improved 0.5 mean Quigley Hein Index.
MIHa 218 % (n) % (n) % (n)
MIH I 105 1.9 (2) 89.5 (94) 8.6 (9)
MIH II 66 4.6 (3) 21.2 (14) 74.2 (49)
MIH III 47 8.5 (4) 10.6 (5) 80.9 (38)
a
Mathu-Muju and Wright (2006).
Note. We defined declined/improved as a deviation greater/lower than 1.
Abbreviations: MIH, molar incisor hypomineralization; SSC, stainless steel
crown.

APPENDIX E

CHANG E IN T HE ME AN NUMB E R OF PWLOF BE FORE

A N D AF TE R T H E RA PY (P A TIE N T RE L AT E D )

PwIoF 

Before After Declined Constant Improved

n % (n) % (n) % (n) % (n) % (n)
Total 78 42.3 (33) 26.9 (21) 6.4 (5) 60.3 (47) 33.3 (26)
LSC 24 0.0 (0) 0.0 (0) 0.0 (0) 100.0 (24) 0.0 (0)
MSC 26 46.2 (12) 26.9 (7) 0.0 (0) 73.1 (19) 26.9 (7)
HSC 28 75.0 (21) 50.0 (14) 17.9 (5) 14.3 (4) 67.9 (19)

Abbreviations: HSC, high-severity category; LSC, low-severity category;

MSC, medium-severity category; PwIoF, problems with the intake of food.